Impact of de Novo Portal Vein Thrombosis on Liver Transplantation Outcomes in the US

Background: Although portal vein thrombosis (PVT) is well-characterized in the pre-transplant setting, de novo PVT following liver transplantation (LT) remains poorly defined. Little is known about its incidence, timing patterns, or impact on long-term outcomes in adult deceased-donor LT (DDLT). Study Design: Using a national multicenter electronic health record network (~101 million U.S. adults), this retrospective cohort identified DDLT recipients without pre-existing or intraoperative PVT (1995–2025). De novo PVT was defined as new thrombosis after postoperative day 1 (POD-1) and classified as early (POD-1–30) or late (>POD-30). Propensity score matching (1:1) balanced demographics, comorbidities, medications, and laboratory data. Outcomes included all-cause mortality, re-transplantation, early allograft dysfunction (EAD), all-cause hospitalization, and rejection. Risks were estimated using Cox and logistic regression, with survival evaluated by Kaplan–Meier analysis. Results: Among 21,758 DDLT recipients, 1,049 (4.8%) developed de novo PVT, 71% after POD-30. After matching (1,018 per group), de novo PVT was associated with higher five-year risks of mortality (aHR 1.29; 95% CI, 1.03–1.63), re-transplantation (aHR 2.08; 1.51–2.88), all-cause hospitalization (aHR 1.19; 1.08–1.31), and rejection (aHR 1.57; 1.37–1.79). EAD odds were also increased (aOR 1.46; 1.22–1.75). Risk patterns persisted across 1-, 3-, and 5-year follow-up. Kaplan–Meier showed lower overall survival (P=.027) and reduced freedom from re-transplantation (P <.0001) in PVT group. Early and late PVT had comparable mortality and hospitalization risks, but late PVT carried higher rejection risk. Conclusions: De novo PVT affects ~5% of DDLT recipients and is associated with worse outcomes. This underrecognized complication warrants closer surveillance and further study.